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The world's most cost-effective health intervention is being overlooked

Dr Saskia Osendarp, Executive Director, Micronutrient Forum.

 

Micronutrients are vitamins and minerals that our bodies need in only tiny amounts but are critical for adequate growth, development, and immune response. Nutrition has never been more important than now as new research suggests that some micronutrients—including folic acid, zinc, selenium, and vitamin D—may play a role in resistance against COVID-19.

A shortage of these micronutrients will have devastating life-long consequences, including lower resistance against infectious and non-communicable diseases, sub-optimal growth, compromised cognitive development, and lower adult productivity levels. Without adequate micronutrient security, we will be less prepared to face continued challenges relating to COVID-19 and future pandemics. Fewer people will live up to their full potential and prosper.

Last November at the Micronutrient Forum CONNECTED Conference, Henrietta Fore, Executive Director of UNICEF, referred to micronutrients as "small but mighty for our world's children". The 2021 Lancet series on Maternal and Child Undernutrition confirms that message and sent out a sharp reminder that—while we have seen improvements in some nutritional outcomes prior to COVID-19's arrival—the world has not made sufficient progress in micronutrient malnutrition among women and children.

We were falling far behind the Sustainable Development Goal targets even before the COVID-19 crisis hit. An estimated two billion people worldwide suffer from micronutrient deficiencies, and this number is likely to grow as a result of the COVID-19 pandemic. In the course of one year, the pandemic has caused a dramatic disruption in people's access to safe and nutritious foods around the world, and the gap between those who can afford good nutrition and those who cannot is growing as global inequity has risen. Nutritious foods are rich in micronutrients, such as fruits, vegetables, and animal-source foods. Burkina Faso by Saskia OsendarpAs in any crisis, including the COVID-19 pandemic, households sacrifice the consumption of these relatively expensive foods to maintain their caloric intake from staple foods. This trade-off has a detrimental short- and long-term impact on the health and livelihoods of the world's most vulnerable families. Without adequate action and investments, global micronutrient deficiencies are setting in play another silent crisis.

And yet, we have evidence-based, cost-effective solutions available and ready to scale. In addition to promoting healthy diets, there are a host of proven micronutrient interventions, such as bio-fortification, fortification, and supplementation. Such interventions are particularly valuable in places where dietary shifts are not immediately available or accessible. The recent Lancet series identified "eleven Samurai" interventions that have been shown to improve health outcomes and save lives. At least eight of these interventions involve micronutrients:

At least eight of these interventions involve micronutrients: 

1) vitamin A supplementation for children under the age of 5 years in deficient contexts,

2) preventive and

3) therapeutic zinc supplementation for the treatment of diarrhea, 

4) breastfeeding promotion and counseling, 

5) maternal calcium supplementation in low intake populations, 

6) maternal multiple micronutrient supplementation (MMS), 

7) large-scale food fortification and 

8) small-quantity lipid nutrient supplements for children 6-23 months of age.

And these interventions belong to the most cost-effective development solutions we have on hand. Economists have long hailed micronutrient supplementation and fortification among the world's best investments with an average return on investment of $35 USD for every dollar spent. At the launch of the Lancet Series, Dr. Shawn Baker, Chief Nutritionist at USAID, said: "nutrition is not competing with other development priorities, it is foundational for the other development priorities."

 

Given their importance for health and development, why are we not investing more in micronutrient interventions when proven solutions are available to scale?

Why is the world not jumping on this opportunity?  Why is there so little discussion about the importance of investing in micronutrient security?

First, investments have lagged because micronutrient interventions have yet to be fully integrated into multi-sectoral approaches across food and health systems. Burkina Faso by Saskia OsendarpEvery stage of the food system is known to have an impact on the micronutrient quality of diets. Now is the time to more fully integrate micronutrients into health system delivery, especially during the first 1,000 days (the time from conception to two years of age) when micronutrient needs are extremely high.

Second, several successful micronutrient interventions may have become the victim of their success. In many low- and middle-income countries, salt iodization and vitamin A supplementation programs have successfully and significantly reduced the manifestations of goiter and iodine deficiency disorders and vitamin A deficiency, and related night blindness. This impressive achievement has led to assume that investments in these interventions are no longer required: the prevention paradox.

Finally, insufficient data on micronutrient status means that public health policymakers and planners often have to operate in the dark when trying to identify where to target these critical nutrition interventions. Micronutrient data gaps, particularly micronutrient status data for women, were highlighted in the Lancet Series as the most vital data gap to be addressed. The dearth of data prevents accurate mapping of the global burden of micronutrient deficiencies despite their significant contribution to reproductive health and productivity.

 

What should we do to turn the tide?

The good news is that 2021 has been named the U.N. Year of Action on Nutrition with pivotal moments for accelerated action — the U.N. Food Systems Summit in September and Tokyo's Nutrition for Growth Summit in December. These events provide all stakeholders working in food systems and nutrition with global platforms to make bold investments and commitments to sustainable multi-sectoral policies, plans, and initiatives across food- and health systems to alleviate micronutrient deficiencies.

Micronutrient security needs to become front and center at these summits with bold SMART commitments from countries, donors, the private sector, and other stakeholders to:

  1. Finalize the unfinished agenda and continue investments in existing micronutrient interventions that have shown to save and improve lives, such as vitamin A supplementation in young children, salt iodization, zinc supplementation for diarrhea, and promotion and counseling of breastfeeding. 
  2. Leverage new investments opportunities that have a strong evidence base, are ready to scale and can integrate micronutrient interventions across global and country food and health systems: Large Scale Food Fortification, Multiple Micronutrient Supplementation for pregnant women, and small-quantity Lipid-based Nutrient Supplementation for children 6-23 months of age to reduce childhood stunting, wasting, and other forms of undernutrition.
  3. Double down on investments to close the vast micronutrient data gap. New investments, tools, and proxy measures are needed to assess micronutrient status and intakes in individuals to estimate the global prevalence of micronutrient malnutrition and help monitor and target interventions.
  4. Invest in ensuring an integrated delivery and implementation of micronutrient interventions across a continuum of food and health systems. The Lancet series confirmed that multi-sectoral approaches are feasible and are instrumental in reducing malnutrition rates. There are no silver bullets in nutrition, and this is also the case for micronutrient malnutrition. We need an integrated approach from the soil to the fork and beyond.

 

Micronutrient malnutrition may be an invisible form of malnutrition, yet efforts to address micronutrient deficiencies do not need to suffer from the same fate. We have the evidence, cost-effective solutions, and the opportunities for investing in a range of micronutrient interventions across food and health systems and in data generation innovations to fill the micronutrient data gap. The Micronutrient Forum remains committed to working with partners to make this a reality and build a healthier future for millions of women and children.

If not now, then when?

 

Short bio for Dr Saskia Osendarp:

Saskia Osendarp is the Executive Director of the Micronutrient Forum, an international expert organization and knowledge broker on micronutrient malnutrition, based in Washington DC. She has more than 25 years of experience in international nutrition research in the public and private sectors and is a visiting associate professor Nutrition and Health at Wageningen University in the Netherlands.

Dr Saskia OsendarpA native of the Netherlands, Saskia holds an MSc and Ph.D. in Nutrition from Wageningen University & Research. Dr. Osendarp lived and worked for seven years at the ICDDR,B, Bangladesh, and spent ten years in Unilever as a Lead scientist in micronutrients and child nutrition. From 2012 to 2019, she worked as an independent consultant for international NGOs, academia, and research institutes.

Since winning the Young Investigator Award in the late 1990s from the American Society for Clinical Nutrition, Saskia Osendarp has built a strong record of academic, public health, and private-sector research and innovation achievements. She has authored more than 50 peer-reviewed publications and book chapters and has led cross-functional research teams on innovative products through public-private partnerships.

Dr. Osendarp is the founder and former co-chair of the Netherlands Working Group on International Nutrition (NWGN), a multi-sectoral working group to promote nutrition-specific and nutrition-sensitive approaches in evidence-informed policies. Recently, she has been a co-founder and co-lead of the Standing Together for Nutrition Consortium, a collaboration of experts working in nutrition, food systems, health, and economics, analyzing the impact and responses of the COVID19 crisis on malnutrition.

 

Photo credit: Burkina Faso by Saskia Osendarp